COUNTY OF ONONDAGA John H. Mulroy Civic Center
Department of Adult and 421 Montgomery Street, Syracuse, NY 13202
Long Term Care Services (315) 435-3355 FAX (315) 435-3279
Joanne M. Mahoney, County Executive Robert Long, MPA, Commissioner
Lisa D Alford, MA, Deputy Commissioner
Barry L Beck, LMSW, Deputy Commissioner
Onondaga County SPOA
Permission to Use and Disclose Confidential Information
SPOA for Adults (315) 435-3355 x 4695 SPOA Fax (315) 435-3279
This form is designed to be used by organizations that collaborate with one another in planning, coordinating, and delivering services to persons diagnosed with mental disabilities. It permits use, disclosure, and re-disclosure of confidential information for the purposes of care coordination, delivery of services, payment for services and health care operations. This form complies with the requirements of § 33.13 of the New York State Mental Hygiene Law, federal alcohol and drug record privacy regulations (42 CFR Part 2), and federal law governing privacy of education records (FERPA) (20 USC 1232g). It is not for use for HIV-AIDS related information. Although it includes many of the elements required by 45 CFR 164.508(c), this form is not an “Authorization” under the federal HIPAA rules. An “Authorization” is not required because use and disclosure of protected health information is for purposes of treatment, payment or health care operations. (See 45 CFR 164.506.)
1.I hereby give permission to use and disclose health, mental health, alcohol and drug, and education records as described below.
2.The person whose information may be used or disclosed is:
Print Name: ______(sign on next page) Date of Birth:
3.The information that may be used or disclosed includes (check all that apply):
Mental health records
Alcohol/Drug Records
School or Education Records
Health records
All of the records listed above
4.This information may be disclosed by:
Any person or organization that possesses the information to be disclosed
The persons or organizations listed in Attachment A
The following persons or organizations that provide services to me:
______/ ____________/ ______
5.This information may be disclosed to:
Any person or organization that needs the information to provide service to the person who is the subject of the record, pay for those services, or engage in quality assurance or other health care operations related to that person.
The persons or organizations listed in Attachment A
The following persons or organizations:
______/ ____________/ ______
6.The purposes for which this information may be used and disclosed include:
- Evaluation of eligibility to participate in a program supported by the Onondaga County Department of Mental Health;
- Delivery of services, including care coordination and case management;
- Payment for services; and
- Health Care Operations such as quality assurance.
Onondaga County SPOA
Permission to Use and Disclose Confidential Information (con’t.)
- I understand that New York and federal law prohibits persons that receive mental health, alcohol, or drug abuse, and educationrecords from re-disclosing those records without permission. I also understand that not every organization that may receive arecord is required to follow the federal HIPAA rules governing use and disclosure of protected health information. I herebygive permission to the persons and organizations that receive records pursuant to thisauthorization to re-disclose the record and the information in the record to persons ororganizations described in paragraph 5 for the purposes permitted in paragraph 6, but for noother purpose.
- This permission expires (check applicable box):
On
Upon the following event:
- This permission is limited as follows:
Permission only applies to records for the following time period: to
Other limitation:
- I understand that this permission may be revoked, and understand that if thispermission is revoked, it may not be possible to continue to participate in certain programs. I will be informed of that possibility if I wish to revoke this permission. I also understand that records disclosed before this permission is revoked may not be retrieved. Any person or organization that relied on this permission may continue to use or disclose records and protected health information as needed to complete work that began because this permission was given.
I am the person whose records will be used or disclosed. I give permission to use and disclose my records as described in this document.
SignatureDate
I am the personal representative of the person whose records will be used or disclosed. My relationship to that person is______.
I give permission to use and disclose my records as described in this document.
SignatureDate
Print Name
Attachment A
This permission to disclose records applies to the following organizations and people who work at those organizations. These organizations work together to deliver services to residents of OnondagaCounty.
Altamont
ARISE
AuburnMemorialHospital
Catholic Charities
Center for Community Alternatives
Central New York Services
Chadwick Residence
CNYOPWDD
Community General Hospital
ConiferPark
Contact Community Services
Crouse Hospital and 410 Crouse.
Hillside Children’s Center
HuntingtonFamilyCenter
Hutchings Psychiatric Center
Interfaith Works of CNY
Jewish FamilyCenter
Kalet’s Adult Residence
Legal Aid Society of CNY
Liberty Resources and the BrownellCenter
Loretto Community Residences
Mental Hygiene Legal Services
NewarkWayne Hospital
OnCare, ACCESS
Onondaga Case Management Services
Onondaga County:DSS,Adult Protective,Dept of Adult and LTC Services
Onondaga Nation Healing Center
Oswego Hospital Behavioral health
Salvation Army
Spanish Action League
St. Joseph’s Hospital Health Care
Syracuse Behavioral Health
SyracuseCommunityHealthCenter
Syracuse Housing Authority
Syracuse Rescue Mission
Syracuse Veteran’s Administration
Access CNY
UpstateMedicalUniversity
Vera House
Access – VR
YWCA
YMCA
HHUNY
St. Elizabeth’s Hospital
St. Luke’s Hospital
Cortland HHC
CNY Legal Services
ACR Health
Hope Connections
Rev.12/11/14